Saturday, May 30, 2015

The assessment of communication skills is vital
component of a comprehensive assessment for children with autism spectrum
disorders (ASD). A best practice communication assessment should provide
information about the child’s communicative abilities in both the verbal and
nonverbal domains, and should not be limited to the formal, structural aspects
of language (e.g., articulation and receptive/ expressive language functioning).
Particular attention should be given to the pragmatic, social communicative
functions of language (e.g., turn taking, understanding of inferences and
figurative expressions) as well as to the nonverbal skills needed to
communicate and regulate interaction (e.g., eye contact, gesture, facial
expression, and body language).

Assessments to identify
pragmatic language deficits are not as well developed as tests of language
fundamentals. Few standard measures are available to assess these skills in
higher functioning children with ASD. Valid norms for pragmatic development and
objective criteria for pragmatic performance are also limited. Available
standardized instruments that focus specifically on pragmatic language include
the Test of Pragmatic Skills (TPS), the Comprehensive Assessment of Spoken
Language (CASL), the Test of Pragmatic Language, 2nd Edition (TOPL-2), the Test
of Language Competence (TACL), the Children's Communication Checklist-Second
Edition (CCC-2) and the Pragmatic Language SkillsInventory (PLSI).

Description

The Pragmatic Language
Skills Inventory (PLSI) is a norm referenced rating scale designed to assess the
pragmatic language skills of children between 5 and 12 years of age. It can
also be used to specify therapy goals for these children, conduct follow-up
evaluations, and document progress. The PLSI consists of 45 items that comprise
three subscales (each with 15 items):

The test takes 5 to 10 minutes
to complete by an adult (e.g., parent, teacher, teacher assistant) who assigns
each item a score from 1 to 9 based on his or her knowledge of the child and
that of children of the same age and gender regarding a particular skill (e.g.,
writing a good story, taking turns in conversation, asking for help or favors).
The authors specify that the rater should know the child well and be familiar
with that child's language skills. Scoring and interpretation are made by a qualified
examiner (e.g., speech-language pathologist, school psychologist).

Once the rater has assigned
scores for all 45 items, the examiner derives percentile ranks and standard
scores (mean = 10, SD = 3) for each of the subscales. Standard scores for the
three subscales are summed to determine a child's Pragmatic Language Index
(PLI) score (mean = 100, SD = 15) and overall percentile rank. The PLI is
considered the best estimate of a student’s pragmatic language ability and the
score that should be used by examiners to identify students who may have a
pragmatic language deficit. Descriptive scores for the subscales and PLI range from
“Very Poor” to “Very Superior.” Generally, scores in the Below Average, Poor,
and Very Poor ranges suggest a pragmatic language disorder (PLI < 89).

Psychometric
Characteristics

The PLSI was standardized
on 1,175 students (610 boys, 565 girls) between 5 and 12 years of age. The
sample represents the U.S. population of school-age children with respect to
geographic region, gender, race, ethnicity, and disability status. Reliability
data are reported in the manual and indicate high levels of internal
consistency, excellent interrater agreement, and good test-retest reliability.

The test manual also
reports information for content, criterion, and construct validity. Construct
validity is reportedly high. Criterion-related validity (concurrent validity) was
established by correlating scores of the PLSI with performance on the Test of
Pragmatic Language (TOPL). There was a strong relationship between the two
measures, indicating that the PLSI and TOPL measure very similar constructs
(e.g., pragmatic language). The diagnostic validity of the test was assessed by
comparing test scores for a group of 40 students with disabilities (autism, learning
disability, attention-deficit/hyperactivity disorder, and intellectual disability),
a group of 45 gifted and talented students, and the normative sample. As
expected, the PLI scores for the students with disabilities were significantly
lower than those in the other two groups. Students with autism and intellectual disability received the lowest scores among the various diagnostic groups.

Conclusion

Speech-language
evaluations for any child with communication concerns should include a
screening of the child's social-communication skills. Norm-referenced parent
and teacher report measures such Pragmatic Language Skills Inventory (PLSI) provides
a time-efficient option for screening children's social-communication skills.
If such screening reveals concerns about a child's skills, a more comprehensive
evaluation should be completed.

As with all tests, the
PLSI has strengths and weaknesses. A strength is its standardization with a
representative sample of the U.S. population. The PSLI also demonstrates high
levels of internal consistency, excellent interrater agreement, good
test-retest reliability, and correlates highly with Test of Pragmatic Language
(TOPL). The record forms are clear and easy to follow for the many individuals
who are likely to administer, score, and interpret the test. The PLSI has an especially
important advantage of sampling pragmatic skills in the child’s natural
environment.

A relative weakness
involves the selection of an individual who knows a child well enough to accurately rate his or her pragmatic skills. Although no special training is
required to make PSLI ratings, the rater is expected to have some basic
knowledge and experience with behavior rating scales. According to the manual,
the rater should also “have a good grasp of what is typical or average behavior
for the child's age and gender.” Consequently, it may be problematic to assume
that a parent, teacher's assistant, or classroom teacher would know when a
child was advanced, average, or behind on the type of pragmatic abilities assessed
on the PLSI. It should be noted, however, that the examiner can complete the
PLSI with teachers in a structured interview format. Although the authors
conclude that “The work we have done so far should be sufficient to establish
the PSLI as a promising alternative way of identifying students who have a
pragmatic language disorder,” further research is needed to examine the instrument’s accuracy (sensitivity) in predicting group membership (normative
sample and clinical groups).

In conclusion, the PSLI is
a brief, quantitative measure based on naturalistic observations of parents and
teachers that can be used as an effective screener in clinical or educational
settings, an aid to clinical diagnosis, or a measure of response to
intervention. Of course, the PSLI should
not be used in isolation to make decisions regarding classification and
intervention planning. Results from other instruments, direct observations, and
parent interviews provide valuable information for identifying social communication deficits in children on the autism spectrum (see Wilkinson for a description
of assessment domains and recommended measures).

Monday, May 11, 2015

Children with autism
spectrum disorders (ASD) frequently have co-occurring (comorbid) psychiatric
conditions, with estimates as high as 70 to 84 percent. A Comorbid disorder is
defined as a disorder that co-exists or co-occurs with another diagnosis so
that both share a primary focus of clinical and educational attention. Although
anxiety is not a defining characteristic of ASD, prevalence rates are significantly
higher in children with ASD than in typically developing children, children with
language disorders, chronic medical conditions, disruptive behavior disorders,
and intellectual disability or epilepsy. In fact, research suggests that
approximately one-half of children with ASD would meet the criteria for at
least one anxiety disorder. Several studies have also reported a bidirectional association
between internalizing disorders and autistic symptoms. For example, both a
higher prevalence of anxiety disorders has been found in ASD and a higher rate
of autistic traits has been reported in youths with mood and anxiety disorders.
Individuals with ASD also appear to display more social anxiety symptoms compared
to typical control individuals, even when these symptoms are clinically
overlapping with the characteristic social problems typical of ASD. With
comorbidity rates so elevated in the ASD population, treatment options for
anxiety have become increasingly important.

Cognitive-Behavioral Therapy

There is a strong evidence
base for the use of cognitive-behavioral therapy (CBT) interventions for
depression and anxiety in non-ASD populations. There are a variety of CBT
approaches, but most share some common elements. The primary goals of
traditional CBT are to identify and challenge dysfunctional beliefs,
catastrophic cognitions, and automatic thoughts as well as change problematic
behavior. With a therapist’s help, the individual is encouraged to challenge his
or her beliefs and automatic thoughts through a variety of techniques. Through
CBT, the individual learns skills to modify thoughts and beliefs, as well as
problem-solving strategies to improve interaction with others in effective and
appropriate ways, thereby promoting self-regulation.

CBT models for the
treatment of anxiety attempt to create a new coping pattern by using behavioral
techniques such as modeling, exposure, and relaxation as well as cognitive
techniques addressing cognitive distortions and deficiencies. These treatment
models generally emphasize four critical components of therapy: assessment,
psychoeducation, cognitive restructuring, and exposure. Using these four
components, CBT has been shown to be an empirically supported treatment for
typically developing children with anxiety issues. The most commonly used
techniques to treat anxiety in children are exposure, relaxation, cognitive
restructuring, and modeling in that order.

Cognitive-Behavioral Therapy for ASD

Although CBT has been
shown to be an effective empirically supported treatment for typical children,
there is a question as to whether or not it can be used with other populations.
In recent years, there have been a number of attempts to adapt CBT for children
and teens on the autism spectrum. Although there is no agreed upon set of
modifications, there appears to be a general consensus that with certain
specific modifications, CBT can be used to effectively lessen anxiety symptoms in
higher functioning children with ASD. Evidence from the current literature
supports a specific blend of techniques and strategies as the most effective
approach to modify CBT for use with children who have an ASD. The primary
modifications to CBT that have been shown to make them more viable for anxious
children with ASD are the development of disorder specific hierarchies, the use
of more concrete, visual tactics, the incorporation of child specific
interests, and parent participation.

A study published in the Journal
of Child Psychology and Psychiatry illustrates how a standard CBT program
can be adapted to include multiple treatment components designed to accommodate
or remediate the social and adaptive skill deficits of children with ASD that
serve as barriers to anxiety reduction. The study tested a modular CBT program incorporating
separate modules focusing specifically on deficits associated with ASD such as
poor social skills, self-help skills, and stereotypies as well as a modified
version of a traditional CBT protocol utilizing primarily cognitive
restructuring and exposure techniques. The participants were forty children
(7–11 years of age) who met the criteria for ASD and one of the following
anxiety disorders: separation anxiety disorder (SAD), social phobia, or
obsessive-compulsive disorder (OCD). They were randomly assigned to 16 sessions
of CBT or a 3-month waitlist (36 children completed treatment or waitlist). The
CBT model emphasized coping skills training (e.g., affect recognition,
cognitive restructuring, and the principle of exposure) followed by in vivo
exposure. The parent training components focused on supporting in vivo
exposures, positive reinforcement, and communication skills. Independent
evaluators blind to treatment condition conducted structured diagnostic
interviews and parents and children completed anxiety symptom checklists at
baseline and posttreatment/postwaitlist. The researchers found that 92.9% of
children in the active treatment group met criteria for positive treatment
response post-treatment compared to only 9.1% of children in the waitlist
condition. In addition, 80% of children in the active treatment group were
diagnosis free at follow up. From these results, it is reasonable to draw the
conclusion that with specific modifications, CBT can be an effective treatment
for children with ASD and concurrent anxiety disorders.

Conclusions

The above referenced
study, together with case studies and other clinical trials, provides evidence
that incorporating disorder specific hierarchies, use of more concrete, visual
tactics, incorporation of child specific interests, and parental involvement can
facilitate successful results when conducting CBT for anxiety in children with ASD.
Although there is support for the efficacy of an enhanced CBT program, there
are some limitations to these modifications and adapted models. Specifically, the
child’s level of functioning, variation in the use of each modification, and
the utilization of different CBT programs across studies affect the
generalization of the outcomes. Moreover, there is a need to examine to what
extent CBT with these modifications could be used with more severe cases of ASD
or in cases where there is more severe intellectual impairment. Children with
higher functioning ASD may be able to better process the cognitive components
of traditional and modified CBT than those who are lower functioning.
Additionally, different CBT programs may emphasize different components of CBT
making it difficult to determine which components are the most critical for
treating anxiety in children with ASD. The next step for future research should
be to focus on developing a standardized approach to treatment which
incorporates specific modifications, randomized clinical trials to test the
approach, and explorations of the boundaries within the ASD population for use
and effectiveness of treatment. Given the elevated comorbidity rates, finding
an effective, empirically supported treatment for anxiety in children with ASD
is critical.

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